Evaluation of lung and abdominal point-of-care ultrasound congestion findings at discharge to predict rehospitalization and death in adults with acute heart failure: systematic review and metaanalysis
E Acosta Gutierrez, S Velasco Malagon, S Salinas, C Espinosa, K Estrada-OrozcoAbstract
Background
Congestion is a central pathophysiological feature of acute heart failure (AHF). However, its definition and, therefore, depletive therapy and discharge decisions remain challenging for clinicians. Point-of-care ultrasound (POCUS) is a tool that might allow the evaluation of organic congestion; however, it is unclear whether the evidence of ultrasound congestion is sufficient to impact the risk of rehospitalization and mortality in these patients.
Aim
To estimate the value of findings suggestive of organic (pulmonary, hepatic, portal, and renal) congestion using POCUS, on the day of discharge, as a prognostic factor for rehospitalization and mortality in patients with AHF.
Methods
Systematic review of prognostic studies. We searched in MEDLINE, Embase, LILACS, Cochrane Central Register of Controlled Trials, Consortium for the Management of Health Information, National Technical Information Service, Google Scholar, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform portal. Reference lists of previous reviews and the articles included were screened for additional studies as well. Studies were eligible if they included hospitalized adults with AHF, who were evaluated with POCUS on the day of their discharge to estimate congestion using portal, hepatic and renal Doppler patterns, as well as the lung ultrasound; followed-up for up to 180 days and reported rehospitalization for heart failure decompensation, all-cause mortality, or a combination of both as outcomes. Measures of association used were odds ratio and hazard ratio. The summary of the weighted effect was performed using a random-effects meta-analysis. For the assessment of the certainty of the evidence, we used the adaptation assessment of GRADE components for prognostic studies.
Results
Twenty-two studies involving 2838 patients met the inclusion criteria; of those, seventeen were included in the quantitative analysis. Sixteen studies evaluated pulmonary congestion as a prognostic factor for the outcomes of interest. At 180 days the evidence of pulmonary congestion was associated with a higher risk of the combined outcome of death and rehospitalization OR 4,17(IC95% 2,59-6,69), at 90 days and 30 days, those findings remained OR 4,91 (IC 95% 1,69-14,26) and OR 3,71 (IC95% 1,99-6,90). In the case of abdominal organs, only two studies evaluated the association between echographic finding of congestion defined by VExUS score >1 with rehospitalization up to 180 days OR 3,59 (IC 95% 1,32-9,81). The results with disaggregated outcomes are described in Figure 1.
Conclusion
Available evidence suggests that residual pulmonary and abdominal congestion, assessed with POCUS at the time of hospital discharge, might be associated with an increase in the risk of adverse outcomes up to 180-day follow-up. However, the certainty of evidence is low to very low, underscoring the need for larger studies with robust methodology to confirm these findings.Forest plotsFor image description, please refer to the figure legend and surrounding text.